While there are common themes among people with disordered eating every individual is unique. Columbus Park is known for a highly personalized approach and tailor-fit treatments. After thorough evaluation and clarification of client goals, we outline a treatment plan, including a specific and deliberate individual therapeutic approach.
There are specific individual therapies with strong research backing that we most often turn to as our first-line interventions. The treatments we use most in our adult patients are Enhanced Cognitive Behavioral Therapy (CBT-E) and Dialectical Behavior Therapy for Eating Disorders (DBT-ED).
While these are well-established, structured therapies, they should fit the client “like a glove” which means that the therapy is tailored and tweaked ongoing to achieve desired results. You should never be six months into treatment only to be questioning if there’s been any change. At Columbus Park, we monitor progress constantly to be sure that we adapt as needed to stay on course. Treatment is a collaborative process, driven by the client with the therapist serving as a supportive, empathic, and informed “co-pilot.”
What is CBT-E?
There’s been a great deal of research over the last twenty years as those in the medical community seek to isolate the most effective methods for treating eating disorders. Consistently, the research comes back to Cognitive Behavioral Therapy, and specifically the newest version of CBT for eating disorders called Enhanced CBT (or CBT-E), as the frontrunner for outpatient treatment of eating disorders in adults.
CBT-E is a transdiagnostic model, which means that it’s designed to treat any eating disorder behaviors whether they occur as part of anorexia, bulimia, or binge eating (or any disordered eating that might not fall into a specific category). It may sound strange that the same treatment might be used to treat all of these seemingly distinct and separate conditions. That said, these disorders at their core share many of the same features; in particular, extreme concern with weight and shape and/or difficulty coping with strong emotion. These factors, overvaluation of shape and weight, and mood intolerance (difficulty tolerating feelings) are known to be triggers to behaviors like overeating, restricting, or purging.
CBT-E is a treatment that should “fit like a glove.” While it is highly structured and specific, it is designed to be customized to each individual and to address the factors that are most responsible for the persistence of the eating disorder.
CBT-E is a relatively short-term, time-limited, individual outpatient therapy. CBT-E is offered in two doses: the standard structure for bulimia and binge eating disorder is 20-sessions over 20-weeks. For anorexia, the treatment duration is longer, more like 40-weeks, since weight restoration is necessary. For all conditions, the treatment sessions are more frequent at the start (2x per week for the first 4-6 weeks) and then gradually spread out over time.
Stage 1 CBT-E
CBT-E is structured in four stages. The first stage is focused on helping the client establish a regular and consistent pattern of eating. We focus on monitoring intake to increase awareness of one’s eating patterns, planning ahead, and timing meals thoughtfully to support normalized nutrition throughout the day. In Stage One of CBT-E, the client begins to understand the factors that keep them locked into an eating struggle. We call these factors “maintaining mechanisms.” These maintaining mechanisms include chronic or yo-yo dieting, rigid food-related rules, weight preoccupation, and negative mood states that impact one’s eating.
Typically in Stage One, we begin to see a pattern of regular eating emerge as we refine our understanding of the factors fueling the problem and learn and practice a host of strategies designed to support the normalization of eating. These first 8-10 sessions are critically important. We want to see a strong start with a great deal of movement towards regular eating.
Stage 2 CBT-E
During Stage Two of CBT-E, we review progress to date, identify obstacles, and map out a plan for Stage 3. This is a relatively short stage, typically 2 sessions over 2 weeks. In this phase of treatment, we want to articulate clearly exactly what is fueling the remaining disordered behaviors or thoughts and then outline how we’ll address these triggers in the next phase of treatment.
Stage 3 CBT-E
Stage Three of CBT-E targets and defuses the maintaining factors. This stage is typically about 6 sessions over 6 weeks. Here is where we will explore things like over-concern with weight and shape, persistent restrictive or rigid eating styles, and event or mood-related eating behavior. These factors are challenged systematically. In some cases, extreme perfectionism, low self-esteem, and/or interpersonal difficulties may be areas that also need further exploration and treatment.
Stage 4 CBT-E
Stage Four is about ending well; this stage is generally 4 sessions spread out over 8 weeks. In ending well, we shift to a focus on the future and how to reduce one’s vulnerability to relapse. At this point, the client knows themself well and can recognize the triggers to ED behaviors. The therapist, of course, is available down the road if for any reason there’s a need to revisit. That said, after complete CBT-E treatment, one should have all the tools needed to maintain a strong recovery for the long term.
If you’d like to learn more about CBT-E or confirm if it’s the right treatment for you, please don’t hesitate to contact us. Our therapists are experts in delivering CBT-E treatment. We would start with a comprehensive assessment so we can understand your struggles fully and confirm if CBT-E is the best course for you.
What is DBT-ED?
Over the last few decades, there has been a great deal of research on eating disorders, with several treatment models yielding satisfactory results for many patients. That being said, with traditional, first-line eating disorder treatments, many of those with eating disorders do not experience remission of symptoms or symptoms do remit but then relapse over time.
Patients with complex presentations such as a dual diagnosis of borderline personality disorder, substance abuse, chronic suicidality/self-harm behaviors, or with emotion regulation deficits (difficulty coping with emotion) may not reliably respond to the first-line eating disorder treatments such as Cognitive Behavioral Therapy or Interpersonal Psychotherapy. There is research suggesting that poor outcomes can be expected even with the gold-standard Family-Based Treatment in adolescent patients with psychiatric co-morbidities, parent psychiatric history, emotion regulation deficits, and/or emerging borderline personality characteristics.
Since some eating disorder sufferers are not helped by standard treatments, robust alternative options are required. Dialectical Behavioral Therapy (DBT) is an established treatment with a strong evidence-base for treating self-injurious behaviors and suicidality along with a wide range of conditions including substance use disorders, post-traumatic stress disorder [related to childhood sexual abuse], treatment-resistant major depression, bipolar disorder, and ADHD. Research also indicates that DBT, and in particular a modification of DBT designed specifically for eating disorders, can be a game-changer for many eating disorder sufferers.
Affect Regulation Theory of Eating Disorders
From the perspective of DBT for Eds (“DBT-ED”), disordered eating behaviors are believed to serve an “affect regulation” function; in other words, behaviors like dietary restriction, binge eating, purging, and compulsive exercise can at least temporarily help the individual escape, numb or block unpleasant emotions. While there may be more adaptive or health-affirming ways of coping with negative feelings and experiences, the idea is that ED behaviors may take over when more adaptive strategies are not readily available to the individual. In eating disorders, things snowball further as perfectionism, guilt, self-criticism and of course, food and body-related thoughts increase, prompting more effort to escape – which means more avoidance through restricting, binge eating, etc. Often these dysfunctional behaviors effectively block emotion in the short term which reinforces the use of the behavior and further locks the individual into the cycle; in the long term, there are serious repercussions physically, socially, and emotionally. In eating disorders, there becomes an overuse of maladaptive coping techniques and an under-use of more adaptive strategies.
DBT For Eating Disorders Basics
DBT-ED focuses on increasing behavioral control by learning and practicing adaptive strategies for tolerating emotions. Clients gain an understanding of the common triggers to behaviors and how to manage those triggers in healthier ways. They practice alternative solutions to problem behaviors and come up with “cope ahead” plans to avoid using problem behaviors in future challenging situations. DBT-ED clients learn about dangerous thinking patterns, like the very common pattern of all-or-nothing thinking which invariably leads to symptom use (i.e. “I blew my eating plan today so I might as well binge”). DBT-ED clients work on increasing awareness of thoughts, feelings, and behaviors, reducing vulnerability to negative emotions, and practicing self-acceptance and self-compassion.
Advantages of DBT-ED
There are distinct advantages to DBT-ED as a treatment for clients who have had multiple treatments without achieving a positive outcome. For one, the DBT focus on building motivation and commitment to change makes it an ideal intervention for eating disorder patients who will often admit that there are aspects of “ED” that they are not eager to give up; common examples of these features are pride in dieting induced weight loss or a sense of control/satisfaction achieved from restricted eating. DBT-ED finds a way to align with the client around even the smallest reasons for wanting to recovery. The DBT-ED provider will help uncover aspects of the illness that are troubling to the patient and build on those examples to drive motivation for change.
DBT-ED also has a well-developed strategy for addressing therapy-interfering behaviors (we call them “TIBs”) that come up frequently in eating disorder care. We know that eating disorders often drive sufferers to protect, conceal or downplay behaviors and drop-out rates are high in ED treatment. DBT-ED is about validating the need for the client to protect their ED (via TIBs like concealing, avoiding, dropping out, etc.) and then working with the client to collaborate in targeting these interfering behaviors effectively. The therapist/client “team” create a method for tracking TIBs and work on identifying the factors that reinforce these behaviors that are ultimately getting in the way of recovery. The provider approaches the TIBs non-judgmentally, with compassion, and with the intention to work together to problem-solve in an effort to decrease TIBs and increase therapy participation which ultimately, leads to the best outcome.
Perhaps one of the biggest benefits of treatment like DBT-ED is that it is structured to target multiple problems at the same time. Many eating disorder patients struggle with other issues in addition to the eating disorder; some common examples include suicidal thoughts, self-harm behaviors, anger dysregulation, interpersonal difficulties, and/or mood symptoms like depression or anxiety. DBT approaches multiple problems in an organized fashion, creating a hierarchy of these targets and then systematically working through the hierarchy until all of the targets are fully addressed.
Typically, DBT starts with behaviors that could be life-threatening – like suicidality or self-injury (after all, how can therapy help if the client is not alive?), and then moves through to address the behaviors that get in the way of therapy actually working (these are the TIBs we were talking about earlier). Once it’s clear that therapy is happening with a safe and present client collaborator, the treatment can move on to address “life worth living goals.” The client and therapist at this stage work together to target those factors that are interfering with the quality of life, the third target level in the treatment hierarchy.
Columbus Park team welcomes clients who may be feeling stuck in their eating disorders, frustrated by failed treatments, or overwhelmed with multiple, challenges. We are grounded in our knowledge of and expertise in DBT-ED which gives us the tools to support our clients forward. We believe that change can and should happen in treatment and that progress should be monitored closely so that we’re sure that you are meeting your goals.